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ASSESSMENT OF AKI IN ER.pptx

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BASMA HASHIM

The document discusses patient assessment for acute kidney injury (AKI) in the emergency room. It outlines a 5 step approach: 1) rule out life threats, 2) assess perfusion, 3) evaluate for edema, 4) perform standard workup including urine and imaging tests, and 5) consider dialysis if indicated. The assessment involves taking a thorough history, examining fluid and electrolyte status, evaluating pitting edema and orthostatic hypotension, ordering relevant labs, and differentiating pre-renal, intra-renal, and post-renal causes of AKI. The goal is to identify underlying issues, monitor for complications, and determine if dialysis is needed based on criteria like acidosis, electroly

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Patient Assessment with AKI in ER BASMAH AL MUSALAM RN,BSN,TOT CERTIFIED ,ICU CLINICAL INSTRUCTOR
Clinical Objectives By the end of this lecture the audience will be able to: Taking history from the patient for kidney function Discuss the assessment of fluids and electrolytes Differentiate pitting edema scale Assess patient for orthostatic hypotension Explain the needed lab test to assess kidney function Discuss the 5 step approach to AKI in the ED
Course Contents Introduction History Taking Fluid and Electrolyte Assessment Pitting Edema Scale Orthostatic Hypotension Assessment Laboratory Studies 5 step approach to AKI in the ED
Introduction Acute kidney injury (AKI), formerly known as acute renal failure (ARF) It is a sudden and often reversible reduction in kidney function, as measured by glomerular filtration rate (GFR) According to Kidney Disease Improving Global Outcomes (KDIGO), AKI is the presence of any of the following: Increase in serum creatinine by 0.3 mg/dL or more (26.5 micromoles/L or more) within 48 hours. Increase in serum creatinine to 1.5 times or more baseline, within the prior 7 days Urine volume less than 0.5 mL/kg/h for at least 6 hours
https://cutt.us/ljyoG ED-AKI 20.421 19.849 17% 71% 11% Pre renal post renal ATN ER ATTENDANCE NON-ED-AKI
History of the patient Patient Profile Personal habits Use of herbs, vitamins, and dietary supplements Illicit drug use Financial problems resulting from illness Sexual function
History of the patient Family History Current Medication Use Hypertension Diabetes mellitus Polycystic kidney disease Chronically swollen extremities Nonsteroidal anti-inflammatory medications Antibiotics Antihypertensive Diuretics Use of iodine-based radiographic contrast media
Past Kidney Studies Urinalysis with proteinuria Creatinine clearance Kidney-ureter-bladder (KUB) radiograph Intravenous pyelogram Kidney ultrasound Renal arteriography Kidney biopsy
Fluid and Electrolyte Assessment
Fluid Status
Fluid Status
Electrolyte and Waste Product Status Chvostek & Trousseau signs sodium, potassium, calcium levels
Electrolyte and Waste Product Status Therapies that can alter electrolyte status ( diuretics, antihypertensives, calcium channel blockers) Gastrointestinal changes (nausea and vomiting Muscle strength (potassium, BUN) Behavioral and mental changes (sodium, BUN levels)
Pitting Edema Scale
Orthostatic Hypotension Assessment
JVP Assessment
Laboratory Studies Assessment Test BUN is increased when kidney function deteriorates. Blood urea nitrogen (BUN) is used to trend kidney function in critical illness as creatine is not re sorbed by the kidney tubules and rises when kidney function deteriorates. Serum creatinine is a newer serum biomarker for early identification of acute kidney injury Cystatin C Electrolyte derangements are frequent in kidney failure including: sodium, potassium, phosphate, calcium, chloride, and bicarbonate.. Electrolyte increased in kidney failure in association with electrolyte and acidbase changes. Anion gap provide valuable information about kidney function, but results are not reliable if the patient has recently been administered diuretics Urinalysis
5 step approach to AKI in the ED
Step 1 Rule out the immediate life-threats Vital signs - Temp, Bp, saturation .etc Hyperkalemia ECG, electrolytes sample Severe acidosis Blood Gas
Step 2 Assess for adequate perfusion are they in shock? Use your history, physical examination and POCUS to assess for perfusion and treat shock (hemorrhagic, vasodilatory, cardiogenic shock etc.) accordingly.
Step 3 Assess for both pulmonary and peripheral edema Assess JVP and lungs with POCUS for pulmonary edema, look and palpate for peripheral edema (including pre-tibial edema, sacral edema) If there is no evidence of pulmonary or peripheral edema, give a fluid challenge.
Step 3 A. AKI with adequate perfusion, with pulmonary edema (with or without peripheral edema) furosemide 1 mg/kg IV (or 1.5 mg/kg IV if on furosemide already) Think about pulmonary renal syndromes other than CHF B. AKI with adequate perfusion, with peripheral edema but not pulmonary edema furosemide 1 mg/kg IV (or 1.5 mg/kg IV if on furosemide already) If no improvement in renal function think about hypovolemia (pre renal) despite peripheral edema Low serum albumin treat underlying cause, and consider hepatorenal syndrome which may require IV albumin Venous insufficiency and/or lymphedema give crystalloid Drug induced edema give crystalloid, reassess offending drug Severe myxedema give L-thyroxine and monitor
Step 4 The golden rules of AKI workup Measure a post-void residual (PVR) with bladder scan or urethral catheter Get a urine dip to look for blood and protein suggestive of nephritic syndrome Monitor urine output ideally with a urethral catheter Avoid nephrotoxins (NSAIDs, ACEi, ARBs, gentamicin etc)
Step 5 Consider imaging for a small subset of post-renal AKI Radiology department imaging should be reserved for those patients who: Do not improve with fluid challenge (making pre-renal less likely), Have a normal urine dip (making intra-renal less likely), Have a post-void residual <100mL (making BPH less likely) Have obvious bilateral hydronephrosis on POCUS These patients warrant further imaging as they might have a rare post- renal bilateral ureteric obstruction cause of AKI such as obstructive metastatic cancer, lymphoma or a kidney stone with a solitary kidney.
The indications for dialysis for any patient with AKI >use the mnemonic AEIOU Acidemia pH<7.1 despite medical management Electrolyte abnormalities hyperkalemia refractory to medical management Ingestion nephrotoxic drug ingestion Overload volume overload resulting in respiratory failure Uremia with bleeding, pericarditis or encephalopathy
References: AKI - Simple ED Approach | Emergency Medicine Cases Overview of the management of acute kidney injury (AKI) in adults UpToDate https://www.stgeorges.nhs.uk/service/renal-medicine/acute-kidney-injury-aki-clinic/ https://www.theinternatwork.com/nephrology-week/2020/4/1/day-1-acute-kidney-injury https://journals.lww.com/cjasn/fulltext/2008/07000/evaluation_and_initial_management_of_acute_kidn ey.11.aspx ds/Patricia_Gonce_Morton_Dorrie_K_Fontaine_Critical_Care_Nursing version 3
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ASSESSMENT OF AKI IN ER.pptx

  • 1. Patient Assessment with AKI in ER BASMAH AL MUSALAM RN,BSN,TOT CERTIFIED ,ICU CLINICAL INSTRUCTOR
  • 2. Clinical Objectives By the end of this lecture the audience will be able to: Taking history from the patient for kidney function Discuss the assessment of fluids and electrolytes Differentiate pitting edema scale Assess patient for orthostatic hypotension Explain the needed lab test to assess kidney function Discuss the 5 step approach to AKI in the ED
  • 3. Course Contents Introduction History Taking Fluid and Electrolyte Assessment Pitting Edema Scale Orthostatic Hypotension Assessment Laboratory Studies 5 step approach to AKI in the ED
  • 4. Introduction Acute kidney injury (AKI), formerly known as acute renal failure (ARF) It is a sudden and often reversible reduction in kidney function, as measured by glomerular filtration rate (GFR) According to Kidney Disease Improving Global Outcomes (KDIGO), AKI is the presence of any of the following: Increase in serum creatinine by 0.3 mg/dL or more (26.5 micromoles/L or more) within 48 hours. Increase in serum creatinine to 1.5 times or more baseline, within the prior 7 days Urine volume less than 0.5 mL/kg/h for at least 6 hours
  • 6. History of the patient Patient Profile Personal habits Use of herbs, vitamins, and dietary supplements Illicit drug use Financial problems resulting from illness Sexual function
  • 7. History of the patient Family History Current Medication Use Hypertension Diabetes mellitus Polycystic kidney disease Chronically swollen extremities Nonsteroidal anti-inflammatory medications Antibiotics Antihypertensive Diuretics Use of iodine-based radiographic contrast media
  • 8. Past Kidney Studies Urinalysis with proteinuria Creatinine clearance Kidney-ureter-bladder (KUB) radiograph Intravenous pyelogram Kidney ultrasound Renal arteriography Kidney biopsy
  • 12. Electrolyte and Waste Product Status Chvostek & Trousseau signs sodium, potassium, calcium levels
  • 13. Electrolyte and Waste Product Status Therapies that can alter electrolyte status ( diuretics, antihypertensives, calcium channel blockers) Gastrointestinal changes (nausea and vomiting Muscle strength (potassium, BUN) Behavioral and mental changes (sodium, BUN levels)
  • 17. Laboratory Studies Assessment Test BUN is increased when kidney function deteriorates. Blood urea nitrogen (BUN) is used to trend kidney function in critical illness as creatine is not re sorbed by the kidney tubules and rises when kidney function deteriorates. Serum creatinine is a newer serum biomarker for early identification of acute kidney injury Cystatin C Electrolyte derangements are frequent in kidney failure including: sodium, potassium, phosphate, calcium, chloride, and bicarbonate.. Electrolyte increased in kidney failure in association with electrolyte and acidbase changes. Anion gap provide valuable information about kidney function, but results are not reliable if the patient has recently been administered diuretics Urinalysis
  • 18. 5 step approach to AKI in the ED
  • 19. Step 1 Rule out the immediate life-threats Vital signs - Temp, Bp, saturation .etc Hyperkalemia ECG, electrolytes sample Severe acidosis Blood Gas
  • 20. Step 2 Assess for adequate perfusion are they in shock? Use your history, physical examination and POCUS to assess for perfusion and treat shock (hemorrhagic, vasodilatory, cardiogenic shock etc.) accordingly.
  • 21. Step 3 Assess for both pulmonary and peripheral edema Assess JVP and lungs with POCUS for pulmonary edema, look and palpate for peripheral edema (including pre-tibial edema, sacral edema) If there is no evidence of pulmonary or peripheral edema, give a fluid challenge.
  • 22. Step 3 A. AKI with adequate perfusion, with pulmonary edema (with or without peripheral edema) furosemide 1 mg/kg IV (or 1.5 mg/kg IV if on furosemide already) Think about pulmonary renal syndromes other than CHF B. AKI with adequate perfusion, with peripheral edema but not pulmonary edema furosemide 1 mg/kg IV (or 1.5 mg/kg IV if on furosemide already) If no improvement in renal function think about hypovolemia (pre renal) despite peripheral edema Low serum albumin treat underlying cause, and consider hepatorenal syndrome which may require IV albumin Venous insufficiency and/or lymphedema give crystalloid Drug induced edema give crystalloid, reassess offending drug Severe myxedema give L-thyroxine and monitor
  • 23. Step 4 The golden rules of AKI workup Measure a post-void residual (PVR) with bladder scan or urethral catheter Get a urine dip to look for blood and protein suggestive of nephritic syndrome Monitor urine output ideally with a urethral catheter Avoid nephrotoxins (NSAIDs, ACEi, ARBs, gentamicin etc)
  • 24. Step 5 Consider imaging for a small subset of post-renal AKI Radiology department imaging should be reserved for those patients who: Do not improve with fluid challenge (making pre-renal less likely), Have a normal urine dip (making intra-renal less likely), Have a post-void residual <100mL (making BPH less likely) Have obvious bilateral hydronephrosis on POCUS These patients warrant further imaging as they might have a rare post- renal bilateral ureteric obstruction cause of AKI such as obstructive metastatic cancer, lymphoma or a kidney stone with a solitary kidney.
  • 25. The indications for dialysis for any patient with AKI >use the mnemonic AEIOU Acidemia pH<7.1 despite medical management Electrolyte abnormalities hyperkalemia refractory to medical management Ingestion nephrotoxic drug ingestion Overload volume overload resulting in respiratory failure Uremia with bleeding, pericarditis or encephalopathy
  • 26. References: AKI - Simple ED Approach | Emergency Medicine Cases Overview of the management of acute kidney injury (AKI) in adults UpToDate https://www.stgeorges.nhs.uk/service/renal-medicine/acute-kidney-injury-aki-clinic/ https://www.theinternatwork.com/nephrology-week/2020/4/1/day-1-acute-kidney-injury https://journals.lww.com/cjasn/fulltext/2008/07000/evaluation_and_initial_management_of_acute_kidn ey.11.aspx ds/Patricia_Gonce_Morton_Dorrie_K_Fontaine_Critical_Care_Nursing version 3

Editor's Notes

  • #5: Normal creatinine level for men=0.74 to 1.35 mg/dl (65.4 to 119.3micromoles/L ( Normal creatinine level for women =0.59 to 1.04 mg/dl (52.2 to 91.9 micromoles/L ( Urine out put 0.5-1.5ml/kg/hr
  • #18: Normal anion gap 4-12meq/l NA+K-(CL+HCO3) NA-(CL+HCO3)
  • #22: Pocus = point of care ultrasongraphy
  • #24: ACEI =angiotensin converting enzyme inhibitor ARBS =angiotensin receptor blocker
  • #25: Benign prostatic hyperplasia (BPH)
  • #26: Benign prostatic hyperplasia (BPH)